Question 1:
(see full question)When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order
You selected: Inspection, auscultation, percussion, palpation
Correct
Explanation: In an abdominal assessment, start with inspection, then auscultation, percussion, and palpation. This is the preferred approach because palpation and percussion before auscultation may alter the sounds heard. ( less) Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 658. Chapter 25: Health Assessment - Page 658
Question 2:
(see full question)The nurse in post-anesthesia recovery (PAR) is caring for a 27-
year-old client following an appendectomy. Twenty minutes after receiving 4 mg of intravenous (IV) morphine for abdominal pain, the
client continues to report abdominal discomfort and requests more morphine. Which action by the nurse is best?
You selected: Observe the abdomen for distention and rigidity.
Correct
Explanation: Continued abdominal pain after administration of IV morphine is an unexpected occurrence and requires further assessment by the nurse to rule out peritonitis or internal bleeding by observing the abdomen for distention and rigidity. Administration of more morphine could mask the cause of the abdominal pain and delay diagnosis of a possible postoperative complication. Applying heat to
the abdomen would increase blood flow to the area and potentially increase pain or internal bleeding. Positioning the client in a knees-
flexed position may relieve the discomfort, but an assessment is needed before any intervention is implemented. ( less)NCLEX Practice TestBank -Interventions Nursing Page 1 Reference: Taylor, C. R. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 658. Chapter 25: Health Assessment - Page 658
Question 3:
(see full question)The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment?
You selected: Palpation
Correct
Explanation: The thyroid gland is assessed by palpation, although it is not normally palpable in some patients.
Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 647-648. Chapter 25: Health Assessment - Page 647
Question 4:
(see full question)The nurse is asking admission interview questions and the client has explained the reason for seeking care. Which of the following is
the most appropriate way to document the response?
You selected: Client describes shortness of breath and increased sputum production.
Incorrect
Correct response: Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." Explanation: The client's reason for seeking care should always be stated in the client's own words.
Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 628. Chapter 25: Health Assessment - Page 628
Question 5:
(see full question)The nurse in the emergency department observes a client experiencing a generalized tonic–clonic seizure. What is the priority
intervention for the nurse to take?
You selected: Assess and maintain the client's airway.
Correct
Explanation: Risk for aspiration is a concern during a seizure because the client will have copious oral secretions that will need to be suctioned and allowed to drain out of the mouth. The nurse should assess the client's airway and maintain it by placing the client in a side-lying position, which will allow the oral secretions to drain from his mouth and not accumulate in his throat and compromise the airway. It is contraindicated to place anything in the mouth of a person who is actively convulsing. Reorienting the client and documenting the seizure are important actions after the postictal phase, but client safety is the priority intervention during a seizure. ( less) Reference: Taylor, C. R. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 625. Chapter 25: Health Assessment - Page 625
Question 6:
(see full question)The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of which of the following?
You selected: Erosion
Incorrect
Correct response: Fissure
Explanation: A fissure is characterized as a deep linear separation in the skin that extends into the dermis. Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss of epidermis and dermis and may bleed. Crusts are dried residue (serum, pus, or blood) on the skin. ( less) Reference: Taylor, C. R. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 641, Table 25-4. Chapter 25: Health Assessment - Page 641
Reference: Taylor, C. R. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 654, Box 25-5. Chapter 25: Health Assessment - Page 654
Question 7:
(see full question)The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds?
You selected: Each lub-dub is one beat.
Correct
Explanation: Each lub (the first heart sound) represents the closure of the
